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Neuro Doctor
Neuro Doctor, Neurologist (MD)
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Experience:  American Board Certified Neurologist, Internal Medicine
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There are multiple punctate foci of increased T2 and Flair

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There are multiple punctate foci of increased T2 and Flair signal throughout the deep white matter and subcortical white matter in both cerebral hemispheres. The apperance is non specific.
There is mildly increased T2 and Flair signal in the periventricular white matter of both cerebral hemispheres.This is most prominent in the left frontal lobe.
There is no intraparenchymal bleed or mass.The lateral ventricles are mildly prominent as are the cortical sulci.There is no shift of midline structures.The midline structures show normal morphology.
There is no area of restricted diffusion within the brain.There is no area of abnormal enhancement
49 male
symptoms light headedness,pressure feeling in head,diffuse headaches,unsteady gait,weakness in arms and legs,tremors,twitching in legs and arms
emgs normal.3 spinal taps all normal.What does this mri specifically state?
Submitted: 3 years ago.
Category: Neurology
Expert:  Neuro Doctor replied 3 years ago.

Thanks for the question.

 

There are several possibilities for the spots in the brain including;

 

1) Migraine headache related

2) Prior head injury related

3) Prior bran infection related (encephalitis, meningitis etc)

4) Vasculitis

5) Chronic Ischemic small vessel diseases of the brain

6) MS (Multiple Sclerosis)

7) Leukodystrophies

8) CADASIL

9) MELAS

10) Idiopathic (cause is not found) etc

 

Not all these above may be applicable in your case; I am just discussing the various possibilities. Yours is most likely #10 in the above list (idiopathic type, and it not uncommon for these spots to be idiopathic in nature).

 

Below I have addressed each of these above mentioned possibilities;

 

Migraine related: These spots are not uncommonly found in patients with history of migraine headache (HA). Of course that is relevant in your case only if you have migraine type HA.

 

Head injury related (if you have this history)

 

Prior infection related (If you have this history)

 

Vasculitis: It is the inflammation of the arteries secondary to autoimmune type of disorders.

 

Chronic ischemic small vessel disease of the brain: It is seen in people who have chronic medical conditions like high blood pressure, diabetes, high cholesterol, triglycerides etc (applicable only if you have these risk factors).

 

MS (multiple sclerosis): The characteristic MRI appearance of the spots & your clinical manifestations will give a clue whether this could MS or not, although MS is bit less likely considering your cerebro spinal fluid x 3 was normal.

 

Leukodystrophies: These are seen mostly in children and extremely rare for your age.

 

CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts & Leuroencephalopathy): It is a hereditary disease where patients experience recurrent stroke or mini strokes.

 

MELAS (Mitochondrial Encephalopathy Lactic Acidosis Stroke like syndrome): This disease is caused abnormality in the mitochondria and patients present stroke or mini stroke like episodes.

 

Idiopathic: Sometimes in spite of an exhaustive work up you may not find any cause then the white matter diseases is called as idiopathic (cause is not found) - which appears to be the possibility in your case.

 

I know you already have seen neurologists and have been worked up. You may see them another time and go through with the above list and discuss with them your case again. They may also do another thorough neurological examination. Basically you are recommended to undergo a repeat thorough reevaluation from different perspectives including your detailed history, thorough clinical examination, meticulous & methodical interpretation of MRI finding (for the different possibilities of this type of MRI finding) etc and hopefully a final diagnosis may be arrived.

 

What I am trying to tell is the spots in the brain may be idiopathic, but it is advised to undergo a reevaluation to make sure nothing else is missed.

 

Please ask me if there are any further questions.

 

Best regards

Dr Sathya.

Customer: replied 3 years ago.

These changes only occured after i was treated with iv rocephon .I was treated on the assumption that i might of had neuro lyme below is am mri that was taken before the iv rocephon

There is no evidence of intracranial mass or hemorrage.The ventricles are normal in caliber and configuration.There is no extra axial collection.There is no restricted diffusion.There are normal arterial flow voids present within vessels at the skull base.The visualized paranasal sinuses and mastoid air cells are clear.There are a few scattered foci of punctate white matter t2 hyperintensity involving the subcortical regions of bilateral frontal lobes.The paraventricular regions are largely spared.The posterior fossa structures and midline structures are unremarkable.

Do you still practice at NYU?

Customer: replied 3 years ago.

To be vasculitis related would there be abnormalities in the spinal fluid?5 doctors here in upstate n.y. thought i could possibly have cns vasculitis.

Expert:  Neuro Doctor replied 3 years ago.

Thanks for all these additional information; I will follow up at the earliest with all the details.

 

Best regards,

 

Dr Sathya.

 

(you may disregard the reply button unless you have more questions before my next post; this message was sent to convey you that I have already received your previous posts, when I am done with the typing of my answers I will follow up myself, and at the earliest, thanx!)

 

Expert:  Neuro Doctor replied 3 years ago.

Once again thanks for all the additional details and also thanks for the waiting.

 

Coming to the discussion;

 

I do not think IV Rocephin has anything to do with these spots, if that was one of your concerns. While Lyme disease can produce brain spots, but we need to prove that you had neuro lyme first (for example with abnormal CSF findings etc). I am not sure whether neuro lyme was definitely confirmed in you or not.

 

Vasculitis is one of the differentials we put for multiple brain spots, but in real practice very very rarely these spots turn out to be vasculitis related. Generally these brain vasculitis are related to autoimmune connective tissue disorders like lupus etc (these are also called as systemic vasculitis). Blood tests like ESR, CRP, ANA etc most often come abnormal when somebody has these diseases.

 

There is an entity called as primary CNS vasculitis, and this condition affects only the brain arteries without any systemic manifestations, and ESR etc blood tests come normal. But primary CNS vasculitis is unusual for your age.

 

But investigation wise - both these types of vasculitis can be demonstrated by a cerebral angiogram like CTA (CT angiogram) - which shows pictures of the brain arteries.

 

I doubt any vasculitis in you so far, but CTA is the commonly ordered investigation to rule out this possibility with more certainty.

 

Sorry, I am currently not in NYU (actually in India now); otherwise I would be very glad to see you in my clinic and evaluate you thoroughly for all the possibilities I had mentioned earlier in the list.

 

Please ask if there are any further questions.

 

Best regards

Dr Sathya.

Customer: replied 3 years ago.
i failed to mention i have ankylosine spondylitis.Were you able to review the differences between the 2 mri reports?How could such a difference be explained when they were only taken 2 months apart from each other?
Customer: replied 3 years ago.
Neuro lyme was a presumed diagnose due to the first mri before the rocephen and also a positive wb igm that only becomes positive when i am on a steroid
Expert:  Neuro Doctor replied 3 years ago.

Thanks for all these additional information; I will follow up at the earliest with all the details.

 

Best regards,

 

Dr Sathya.

 

(you may disregard the reply button unless you have more questions before my next post; this message was sent to convey you that I have already received your previous posts, when I am done with the typing of my answers I will follow up myself, and at the earliest, thanx!)

Expert:  Neuro Doctor replied 3 years ago.

Once again thanks for all the additional details and also thanks for the waiting.

 

Coming to the discussion;

 

Your point is well taken. A CT angio can show whether you indeed developed vasculitis or not. Ankylosing spondyltis is an example of autoimmune disorder and it can rarely trigger vasculitis. But CT angio can tell whether you indeed have vasculitis or not, without this test it will be just guess work.

 

If these spots are lyme related then the spots are not significant now, as long as you took full antibiotic course the lyme must have been cleared from the body by now.

 

Please ask if there are any further questions.

 

Best regards

Dr Sathya.

Customer: replied 3 years ago.

I had a cta angiogram not with a cath inserted but with dye injected in my arm i was told could only show large vessel vasculitis not small vessel.

Would a negative spinal tap rule out cns vasculitis?

Expert:  Neuro Doctor replied 3 years ago.

Thanks for all these additional details and also thanks for the waiting.

 

Yes, it was CTA, if the dye was injected in to the arm. And CTA can show small vessel vasculitis too (the usual brain vasculitis).

 

CNS vasculitis is expected to show at least some CSF changes, like increased protein etc.

 

If CTA & CSF both came ok then like I discussed earlier the spots appear to be idiopathic.

 

Please ask if there are any further questions.

 

Best regards

Dr Sathya.

Customer: replied 3 years ago.
I was told by the radiologist and a neurologist that a cta with the dye injected in the arm is only reliable for showing large vessel vasculitis.
Expert:  Neuro Doctor replied 3 years ago.

Thanks for these additional details, and sorry I couldn't reply earlier as it has become morning at my area only just now.

 

CTA (CT angio) and the conventional angio (dye injected through a catheter directly into an artery - this procedure usually performed through femoral artery in the groin/thigh area) both look at the same sized arteries. They are both indicated for similar conditions like detection of brain aneurysm, vasculitis etc.

 

CTA is nowadays preferred is because it is a simple procedure. It is much easier to inject the dye through a vein (like in CTA) than through an artery (like conventional angio).

 

And CTA is nearly as effective as conventional angio for the detection of aneurysm & vasculitis, however CTA is slightly inferior to conventional angio in this aspect. But the difference is not huge, both are nearly equally effective in detection of the above condition but conventional angio has an edge over the CTA.

 

But they both look at the similar sized arteries (small or large). For the small sized artery vasculitis CTA is slightly inferior to conventional angiogram but CTA too can detect this type of vasculitis. There is some difference in the detection rate between these two angiograms, but it is small.

 

While it is true that as the diameter if the artery gets smaller the conventional angiogram becomes more effective in detecting these arterial diseases compared to CTA, however both are used for detecting pathologies of small sized arteries. In fact CTA is the test nowadays commonly employed for any arterial pathology (small or large sized). While CTA is somewhat inferior to conventional angiogram in detecting the small vessel pathologies but the difference is not huge and many radiologists consider CTA is an adequate and satisfactory alternative for conventional angio.

 

If there is unequivocal suspicion for a smaller sized artery pathology and if CTA doesn't show it then conventional angiogram may be performed and may be helpful (but no guarantee), however in other situations (when the suspicion for small vessel vasculitis is not high) doing conventional angiogram after a failed CTA is not going to increase the yield, it just increases the risk for complications associated with the arterial puncture & catheter insertion (conventional angio).

 

Once again thanks for waiting!

 

Best regards,

 

Dr Sathya.

Neuro Doctor, Neurologist (MD)
Category: Neurology
Satisfied Customers: 3807
Experience: American Board Certified Neurologist, Internal Medicine
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